0008-084 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lia Clas"` '" Exp. Date
674 4 L!
Date I/ d )ty—`Z .Signature of Contractor, yI
5
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business &,Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty sof perjury one of the following declarations
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation;: as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers'. compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier STATE FUNS Policy No. 046-0007,33$
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California,'.
alifornia, and agree that if I should become
subject to the workers' compensation provisions of Section,.3700 of the Labor
Code, I shall fotthw'th comply with those provisions. ,� ' I
Date: r ` Applicant `A `
Warning: Failure to secure Workers' Compensation coverage is 4ufnlawful and
S
hall subject an employer to criminal penalties and civil fines up tot$ 00,000, in
-addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a' permit subject to the conditions and restrictions set forth on his
application.'.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
'construction, and hereby authorize representati:vles of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent)-- r Datea r `
BUILDING PERMIT PERMIT#
DATE VALUATION - LOT (ZC TRACT
$24%11.7.;10 56 294574
JOB SITE
APN
ADDRESS._•68J I? Aj C",.E o j[,A QW 1t � 1 1
-���
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
SPARM CON'fs"MUCTION
M)PXM COMM. OC: lolq
79-295 # Ev€'!F1C) 1AQ'01WA D , -
79-295 F"CRO LA QUJNrADR,
LA i,, U24 A C.A. 42253
LA, Q1,°'.1"AITA CA 92253
(76O 771-194.1 C4.0 2996
USE OF PERMIT
MOLE FAWff DiNlILW(3
SIM -LOT 56 -PLAN MIR . MWIT DOMNOT MCI.UDE'RLOC K IYALL OR
POOI.. 75% PLAN CHECK FEE REDUCTION FOR MULTIPLE ISMS JANC:E OF
SAME PLAN. TYP&
CUSTOM CONSTRUCTION %924.00 8F
PORCHIPATIO nd ,O0 S1'
GARAf1WARPOR'I` (SE) y,�12,09
r, 'i
C`S3�'.�or CON YrRuc.3C3i�i
2402117` 1,
•�,'}:�jggy+gv y.}•�_ k g�pga,�3y��t�p"�1..1�.i1;`
PERMTr .Q i E ISW1V9.17�.ti.0.�i-7i.
y•�:
3 t lra
C.'a-4S'lRUCTIt 14.,?Et 101-000-418-000 $1,133,00
�i
PLAN CHECK IEEE 101-000-439-318 $232.34
MECHANICAL f,72 101.000.421.000
ELI�'.CTIUV...AL M' 101-0()0-420-000 $t59.7•s
,": �e
PLUM BDIC# FEB 101.0(10=419.000 Si7"o3
STRONG MOTION RE - RMID 101-000-241-000
c9RAl INO KE 101.000 23-000 320,00 .
DEVELOPER IMPACT FEE �1,5[►r.00
ART 04 PUBLIC PLACES • RESIC'701-000455-000 $100.29
St -113 -TOTAL E' YCN9F1ZV''CT!013' SAND ):SLAM CTICC5.0
$3,897.03.
+ rt.-1�;£.9S PR.R-PIW) PEW
$0./00
T
. dil PYA T, iVtSf a C+C1:7 •I)VE Riii SO'
RECEIPT ;DATE/
�'i
BY;- ;,-
DATE FINALED
INSPECTOR
f ! 1•'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs /'
Underground Ducts
Forms & Footings L'/
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing j3 D
Compressor
Insulation - Z a
Vents
_
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. lath
FinalPOOLS
Final
-SPAS
BLOCKWALL A PROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral _
Pool Cover
Sewer Connection —
Encapsulation
Gas Piping -
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit zf
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
_
G.F.I.
Smoke Detectors
Temp. Use of Power
Final �O
Utility Notice (Perm)